A Blog on Healthcare from an Indian perspective

The Hindustan Times

The private healthcare sector in India is now increasingly being looked upon as a sector that should focus on doing good rather than being run as a responsible business enterprise. The government wants the private hospitals to be good Samaritans and treat patients at such low prices that the business itself becomes unviable!!!

Essentially, the government wants its duties to be discharged by the private sector.

This is a complete abdication of responsibility on the part of the government and totally unfair to the private sector players and their investors. It is a well-known fact that public healthcare expenditure in India remains abysmally low at under 1.4% of the GDP. This compares poorly even with countries in sub-Saharan Africa. According to the WHO World Health Statistics 2015, the public sector in India spent 1.16% on health as a percentage of the GDP, ranking 187th among 194 countries. A recent report in The Wire says ”global evidence on health spending shows that unless a country spends at least 5-6% of its GDP on health, basic healthcare needs are seldom met”.

Another recent report in The Mint pointed out ”The World Health Organization estimates that India spent about $267 per capita on health care in PPP adjusted terms in 2014—China spent three times that amount, Brazil five times, European nations 10 times and the US 20 times”

To make matters far worse is the fact that much of the funds allocated to the sector remain unutilized. This is nothing less than criminal negligence. Sample these facts reported in The Hindustan Times in August 2017.

”More recently, in a performance audit of the Reproductive and Child Health scheme under the National Rural Health Mission (NRHM) tabled in the Parliament last month, CAG said the cumulative unspent amount in 27 states increased from Rs. 7,375 crore in 2011-12 to Rs. 9,509 crore in 2015-16.”

Since the government allocates a minuscule amount for public health and even spends less, the out-of-pocket (OOP) expenditure in India remains high. In the year 2014-15, 62.42% of health spending was borne by the citizens themselves. Unexpected medical expenditure remains the single largest cause of individual families being pushed below the poverty line. The National Health Policy Draft of 2015 estimated that ”nearly 6.3 crore people are faced with poverty every year because they do not have financial protection for their healthcare needs“.With the OOP remaining high, there is a sense of anger and frustration amongst the consumers and the politicians have been cleverly channeling this palpable anger towards private healthcare providers by painting them as uncaring, profiteering and worse.

Now compare this with what is happening in the private healthcare space in India. A recent report (August 2017) in The Scroll cites a PwC study saying that private health spending in India was more than double the government’s expenditure, at 3.3% of the GDP in 2014. The private sector consisting of individual doctors, clinics, nursing homes, diagnostic chains, trust hospitals and corporate hospitals provide care to more than 80% of our people. A report by the India Brand Equity Foundation (IBEF) published last month points out that healthcare sector in India is the largest employer in the country. The sector is expected to record a CAGR of 16.5% between 2008-2020 and the industry size is expected to grow to USD 280 bn.

The same report quotes Department of Industrial Policy and Promotion (DIPP)”The hospital and diagnostic centers attracted Foreign Direct Investment (FDI) worth US$ 4.34 billion between April 2000 and March 2017.”

A mere glance at this data indicates that while the government has wantonly abandoned its duty of providing good quality healthcare to the citizens of the country, the private healthcare sector continues to make significant investments. Private investments are by definition ”for profit” investments and are made in the rightful expectation of a reasonable return on the capital employed.

Instead of spending scarce public funds on building new infrastructure, decongest government hospitals, ensuring efficient and smooth management of these hospitals and providing greater access to the citizens to public healthcare, the government is busy pandering to the masses through populist measures and what may even be called as bullying.

Populist policy announcements, which are not even clearly thought through are being made every day. It has been announced yesterday that any citizen in the city of Delhi who fails to get timely medical attention in a Delhi government hospital can approach a private healthcare institution and avail of cash-less services, which will be reimbursed to the hospital by the government later at rates, which are very low. The private hospital has no choice but to accept the patient and treat him at government-mandated pricing.

This kind of policy-making, akin to shooting from the hip must stop.

The government should define its own role in the healthcare sector in the country.

It must be said, even though it may sound harsh that the responsibility of providing good quality healthcare to those who cannot afford private healthcare squarely lies with the government.This is a responsibility, which it must not attempt to shirk or palm off to the private sector.

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Fortis Healthcare was aiming to create a Guinness World Records (GWR) record of the maximum cholesterol tests done in a city on a single day and I was nervous. We had been preparing for this day for the last four weeks and the day of reckoning was here.

The previous night I had slept late, mentally going through a check-list of things that we had closed, wondering about all that which may go wrong and hoping for the best the next day. Once, I had ticked off most things on my mental check-list, I slept well and was up bright and early. It was time to see how the last 4 weeks of intense effort would now fructify.

The idea to attempt a world record of cholesterol tests came from Dr. Ashok Seth, the Chairman of Cardiac Sciences, at Fortis in New Delhi. Dr. Seth knows how to throw a challenge to the team. My colleague Jasrita and I had met him to discuss about the World Heart Day and Dr. Seth immediately threw down the gauntlet. He got us excited and committed. He got us thinking and wondering. A simple cholesterol test can serve as a warning sign for heart disease, we can use the test as a marketing device to create awareness about the disease. We hoped to get a few thousand people to come (fasting) to our hospitals on a warm Saturday morning to get their cholesterol levels checked.

Jasrita, Arnab and I got down to serious work. We had to plan and organise the campaign, get the hospitals excited and aligned, find a media partner who can drive home the message and have a diagnostic lab join hands with us in doing the physical testing. Fortis has more than half a dozen hospitals in the National Capital Region, who had to come on-board to participate in the activity. Most importantly, we had to find the money for a big campaign like this.

The Partners

Crayons

We roped in our advertising agency in Delhi as the key partner in developing the communication and for media planning. Crayons, has been working for many years and the CEO of Crayons, Ranjan has been a personal friend for over a decade. The Fortis team and the Crayons team met in their office for a detailed briefing. We took them through the idea, they loved it and saw great possibilities. They were raring to go. Two weeks later, Jasrita and Arnab trooped into my office with the first set of creatives, neatly printed and mounted on boards. The agency was surely putting its best foot forward. Also, they had churned out a lot of work. We had 4 different communication routes and tonnes of creatives. Jasrita, Arnab and I went through all the material calmly, debated and discussed each route and decided to sleep on it. I also asked Arnab to leave it lying around in my office overnight. We also agreed that, while we were attempting a World Record, it would not be appropriate for us to talk about it in our advertising.

The next morning we again went over the entire pile. We discarded two routes and shortlisted two for further discussions with Dr. Seth and Ashish, who is the Chief Operating Officer (COO) of Fortis. We met them on a Wednesday afternoon in Ashish’s office and took them through the ideas and the creatives. We unanimously agreed on a creative route. The die was now cast. Jasrita, Arnab and I would later fine tune the communication, pour over commas and full stops and agonize over every word written in the copy of the communication. We needed to get it just right and we knew that even a single word left out-of-place can leave a bad taste in the mouth.

The Hindustan Times

The Hindustan Times group is the second largest media company in the country and they rule Delhi. We called in the HT team for a briefing early on. They loved the idea as well. Of course, they were keen on our business as these are lean times for folks in the media business, but I would like to believe that they liked the idea more than the commercials. I have always believed that a partner delivers the best, when they buy in an idea. This is exactly what we did with the HT team. Of course, it helped that I knew them well as HT is my former employer and these guys are friends. While we negotiated hard, they eventually gave us a great deal.

SRL Diagnostics

SRL Diagnostics is a subsidiary of Fortis and is the largest diagnostic chain in the country. Jasrita worked hard with them to agree to collecting more than 10000 samples from 20 odd locations spread across the NCR. They were really a difficult bunch and the logistics of the exercise had to be meticulous. The last thing we wanted was to have people having a bad experience while giving samples, or the samples getting mixed up or reporting going haywire. Jasrita nailed everything down. Our favorite term during these days was ”idiot-proof”. We planned to make the entire process idiot-proof, dumb it down so that even the last person in the line should have no difficulty in understanding the process and following it. We meticulously calculated the number of phlebotomists needed at all the sample collection facilities, provided each of them with clear directions and fervently hoped that all will turn-up at the appointed hour. Jasrita wrote mails after mails detailing out a simple process over and over again so that everyone understood.

Guinness World Records (GWR)

Guinness World Records has a process for every record. They sent us reams of information about what all they needed to certify our record. They made us go nuts with their demands about arranging assessors, video-recording of all the sessions, the strict time-keeping, physical inspections of the sites and finally collection and evaluation of all the data. Boy, they are really thorough. They made us go through hoops but we complied on every single count. Jasrita, handled them adroitly, understood their detailed instructions and passed them on faithfully to the operations team. We were always fearful that we may fall foul of their elaborate process and miss out on the record on a technicality. What a pity that would have been.

The BTL Folks

We had a couple of ”Below the Line’ marketing agencies supporting us. They promoted the concept of a free cholesterol test directly to consumers. They went around parks looking for morning walkers, spread awareness in the hospital neighborhoods by distributing pamphlets and getting people to sign on for the test. Thus, one afternoon my wife and I were accosted by a young man at a Barista Coffee Shop, who explained to me what a cholesterol test was and how I can get one done free on Sept 29th at a Fortis facility. Bravo!, we both gladly registered.

Salt Mango Tree

You may wonder, what they are. Salt Mango Tree is in fact our agency for digital advertising. They trawl the internet for us. They also run our digital campaigns. For World Heart Day they promoted us on the Google sites, Facebook and Twitter. They created excitement in the digital world and got us a huge fan following on the net.

While, we had the partners lined up, a big challenge was to get each hospital charged up. We called meetings of the sales people from all the hospitals and, explained to them what we were attempting and asked them to contribute. Each hospital came up with ideas on getting folks to come to the hospital to give their samples. We met many times as a group, discussed progress, new ideas and revised plans. Goals were set, targets were mutually agreed upon and shared. The teams came together. The Corporate Sales teams too joined in. The word spread. We loved it. Aditya Vij, who is the CEO of Fortis Healthcare spoke with me. His big concern understandably was not the record but the customer experience that we were geared to deliver the next day. I assured him that we were ready.

Sept 29th 2012

I reached Fortis Escorts Heart Institute at around 0630 in the morning. I ran into Ashish, who too was wandering in. We had asked him to be the first donor of the day. The program was to begin at 7 in the morning and end at 1230. Even at 0630, we had the waiting area full, with people waiting for the tests. We began with Ashish and there was no looking back. Soon, I started receiving reports of a large turnout at almost all our facilities. The campaign had created a huge amount of excitement. We had people trooping in everywhere. Yet, the processes held up. We did not encounter any chaos anywhere.Everything went according to plan and by 11 we knew we were ahead of the existing record.

By the time we stopped at 1230, we were confident of having set a new GWR record. The GWR assessor took the entire afternoon in ascertaining our claims. He went through reams of physical data, the forms that we had collected and footage from across all our 20 locations. It was a mammoth exercise.

In the evening we assembled for a small function. The GWR representative asked Ashish to hazard a guess about the number of people who came for the test. Ashish who is usually ahead of the curve answered with a broad smile ”14161”. The GWR assessor looked a little abashed, smiled and said ”a very well-educated guess indeed”.

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I learnt about Ramrati from the pages of the Hindustan Times a few days ago. Apparently, the newspaper found her living in a urinal outside of the All India Institute of Medical Sciences (AIIMS), India’s most renowned medical facility located in the heart of the capital. Ramrati had a defective mitral valve and was seeking treatment for her medical condition.

Ramrati hails from a village in the Hamirpur district of UP. She is a mother of 5 and is 50. Needless to say that Ramrati, her husband Bhawani Din and their family lives in abject poverty and can hardly afford cardiac surgery, even at government-run hospitals, which are supposed to treat the poor free, but very often do not. Ramrati traveled to Jhansi for her treatment, from where she was asked to go to the Post Graduate Institute (PGI) of Medical Sciences in Lucknow the provincial capital. From there, she was sent to the AIIMS in Delhi, where she had been languishing in a men’s urinal for close to two and a half month hoping to have her surgery at India’s most premium medical institute.

Bhawani Din mortgaged all of his land to raise Rs. 100000 to fund his wife’s surgery. It would probably have been possible for Ramrati to undergo surgery at AIIMS, but then the hospital is over crowded and Ramrati has to wait her turn and since she has no place to live in Delhi, she found an unused men’s urinal, outside AIIMS and shared it with some other patients in a similar predicament.

Thanks to the story in the Hindustan Times, Ramrati found help. A local NGO found her room to board in a dharamshala and an eminent cardiac surgeon Dr. A. Sampath Kumar, formerly the Head of CTVS Surgery and now at a private hospital, Pushpanjali Crosslay Hospital in East Delhi agreed to operate on Ramrati free of cost.

The newspaper duly wrote about Ramrati’s good fortune also highlighting its own role in bringing succor to her. Pushpanjali Crosslay Hospital too did not miss the opportunity of grabbing headlines by positioning itself as a hospital with a heart. Dr. A. Sampath Kumar, who was part of the team of surgeons who had operated on the Prime Minister a few years ago got an opportunity to present himself as one of the ‘finest’ cardiac surgeon in the country. Pushpanjali Crosslay Hospital, released pictures of a tired looking Ramrati being taken to the hospital for treatment and undergoing treatment at the hospital. AIIMS agreed to refund the Rs. 100000 deposit it had accepted from Bhawani Din.

Well, all this does sound like a fairy tale but it does raise disturbing questions. Why does Ramrati need to run from pillar to post to seek medical attention? Why does she need to travel to Delhi, via Jhansi and Lucknow, when the medical attention she needs can be provided to her in Lucknow? Why does Bhawani Din need to mortgage his land to raise money for his wife’s treatment? Why does Ramrati need to languish for two and half months in a men’s urinal outside India’s best hospital to get treated? What happens if she dies waiting for her turn? Who is accountable for all this? How many Ramrati’s are waiting outside AIIMS and other such facilities desperately seeking medical attention and why no one does anything about it? At the end of the day, who is accountable for Ramrati’s fate?

Now let us look at Dr. Sampath Kumar’s intervention. I would like to believe that he is a genuinely altruistic man and by responding to Ramrati’s predicament, he is only honouring the Hippocratic oath. But look at the way Pushpanjali Crosslay Hospital has gone about talking to the press about the free treatment that Ramrati has been offered by them. There are Ramrati’s photographs with the hospital ambulance serving as a nice backdrop and every mention of Dr. Kumar is followed by a statement that he is now with Pushpanjali Crosslay Hospital. It seems that the hospital wants the media spotlight firmly on itself, somehow the entire things looks way too opportunistic.

While the likes of Anna Hazare and the so-called members of the civil society prepare to commence a Gandhiji like fast, hoping to bring the government down to its knees, who is looking out for the Ramratis of the world. Why don’t we have the civil society empathizing with the poorest of our land and the callousness of our system, which does not care for them? Isn’t the right to reasonably good healthcare a fundamental right derived from the right to life? Isn’t this something to agitate for? How can we have a shining India and a Ramrati’s India existing together and for how long?

And finally, today as we have our netas shamelessly mouthing platitudes to our freedom from the British, we need to look inwards and ask ourselves if Ramrati is free today. Unless we get an answer in the affirmative, India will continue to struggle for real freedom.

PS: I believe Ramrati has since been successfully operated upon and is on the road to recovery

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The whole of the last week The Hindustan Times carried a series of stories highlighting incidents of ‘negligence’ in high profile private hospitals in Delhi. The hospitals featured included Fortis Escorts Hospital, Max Hospitals, Apollo Hospital, Sir Gangaram Hospital and Rajiv Gandhi Cancer Hospital. Now these hospitals in Delhi are the best that we have. While, Hindustan Times has a right to expose cases of negligence in hospitals I am still not sure what purpose was served by these reports.

Here are a couple of points I would like to make about these ‘exposes’.

The cases reported highlighted horrific experiences consumers had in these hospitals. Most people featured in the story lost a loved one because the hospital failed to deliver adequate care and refused to take responsibility for what went wrong. These I am afraid were random cases picked up by intrepid journalists and made for riveting reading. However, the journalists doing these stories did not investigate the reason for these failures. The question why did these hospitals fail in their duty towards their patients remains unanswered. Was the failure a result of a doctor not discharging his duties properly, or was it a failure of the hospitals processes or both? Or was it negligence or an error of judgement on the part of a doctor? Did he deliberately mistreat a patient, was callous in discharging his duties, wilfully deviated from standard medical practices or just did not care enough? Continue reading →

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The world is all agog with the global spread of the swine flu. The outbreak first reported from Mexico has rapidly spread to the United States and Europe. Countries the world over are rushing to identify people with flu like symptoms and those who have a history of having been in Mexico or in certain parts of the United States in the recent past are being carefully screened. The airport officials have been alerted to be on the lookout for people with these symptoms and medical personnel have been stationed at the airports to screen travellers arriving from these parts of the world.

In India a person arriving from the US with flu like symptoms has been detained and admitted in an isolation ward in a local hospital in Hyderabad. The government is busy procuring millions of Tamiflu pills and the drug manufacturers are rushing to cater to this unexpected demand. The newspapers, TV and the digital media is busy putting out stories on swine flu, highlighting the emergency measures being taken the world over to combat the resurgent rogue virus. Theories are being propounded on the impact the virus is likely to have on the economies across the world. The general refrain seems to be as if the recession was not enough, we now have to deal with a real virus running amok. Continue reading →

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Yesterday I came across a piece in The Hindustan Times, which talked about the ‘luxury’ that a hospital now offers. The piece had snaps of fancy chefs offering a choice of cuisine to patients, nurses ‘requesting’ young patients, mostly kids to have their medication and the pretty front office executive (with her ‘May I help you badge’ in place)making ‘guests’ welcome.

This made me remember my grandmother, who is all of 104 years old narrating to me her escapades in hospitals run by the British in colonial India. She had great admiration for the no nonsense English doctors, the stern nurses, who followed orders and paid little attention to patient grievances. She remembers these episodes with a mixture of nostalgia and respect for the efficiency that this system stood for. The food was always what the doctor ordered, the medicines were given like clockwork and chores like sponging were a must-the patient had little choice in the matter. Continue reading →

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Last week my wife dragged me to a late night screening of Singh is Kinng (featuring the inimitable Akshay Kumar and Katrina Kaif) at a nearby multiplex. I was reluctant to go as I had read reviews of the movie in the popular Hindustan Times and the Times of India, who had panned the movie essentially as mindless drivel.

As I sat through the movie, it dawned on me that sometimes ‘mindless drivel’ can also be entertaining!. The movie does not have a real storyline yet it does not have a dull moment. It is quite an incredible entertainer. Continue reading →